Quick facts
Annual Deductible (per insured person)
$50
Annual Deductible (family maximum)
$150
Annual Benefit Maximum (per insured person)
$2,000
Diagnostic & Preventive Services Coverage
100%
Orthodontic Lifetime Benefit Maximum
$1,000
Annual Maximum Carryover
Covered
Basic (Restorative) Services Coverage
80%
Basic (Restorative) Services Coverage (Out-of-Network)
80%
More details (10)
Endodontics (Non-Surgical)
50%
Extractions (Simple)
80%
Major (Restorative) Services Coverage
50%
Major (Restorative) Services Coverage (Out-of-Network)
50%
Oral Surgery (Complex)
50%
Orthodontic Services Coverage
50%
Periodontics (Non-Surgical)
80%
Periodontics (Surgical)
50%
Diagnostic & Preventive Services Coverage (Out-of-Network)
100%
Prosthodontics (Dentures, Bridges, Implants)
50%
Carrier contact
Your member ID card: check the carrier website or app, or ask HR for a copy.
Plan documents
Confirm details with your carrier for current plan information.